OB/GYN Medical Billing & Coding Guidelines.

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OB-GYN Medical Billing & Coding Guidelines2022-11-17T22:11:29+00:00
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OBGYN Medical Billing & Coding thorough Guidelines.

Medical billing & coding gets more complicated every year. Constantly changing Current Procedural Terminology (CPT) codes and various changes related to diagnosis codes within the transition of ICD-10, many practices have faced OBGYN medical billing and coding difficulties. That has eventually resulted in claims denials and has slowed the practice revenue cycle. Moreover, there are several changes and tips that gynecologists should be aware of and must incorporate ICD-10-CM information into their documentation and avoid common compliance traps. Staying up to date with the latest coding changes enables the physician to record patient histories and accurately maintain records. Make sure a team of medical billing experts handles your OBGYN Billing and that payments are made on schedule for the range of services delivered.

Unlike other sections of the American Medical Association Current Procedural Terminology, the coding and billing for OBGYN care differ significantly.

Obstetrics and Gynaecology / Maternity care services typically comprise antepartum care, delivery services and postpartum care. Depending on the patient’s circumstances and insurance carrier, the provider can either:

  • Submit all rendered services for the entire nine months billed on CMS 1500 form.
  • Submit claims based on an itemization of OB GYN care services


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OBGYN Medical Billing & Coding Guide

Keeping track of OB/GYN CPT codes and billing best practices are far from easy. This article explores the key aspects of OB GYN medical billing and breaks down the important information your OB/GYN practice needs to know.

  • Different types of services rendered
  • The split OB packages
  • Complications of pregnancy
  • The global maternity care package
  • CPT Codes
  • High-risk patients

Always remember that individual insurance companies provide additional information, such as the use of modifiers

The Global OBGYN (Obstetrics & Gynecology) Package.

Understanding the Global Obstetrical Package is essential when discussing OBGYN medical billing services for maternity.

Most insurance companies, including Blue Cross Blue Shield, United Healthcare, and Aetna, reimburse providers for services rendered throughout the maternity period for uncomplicated pregnancies using the global maternity codes.

The AMA CPT now describes the provision of antepartum care, delivery, and postpartum care as part of the “total obstetric package.” (Reference: Page 440 of the AMA CPT codebook 2022.)

The instruction has been conveyed to the coder to utilize the relevant stand-alone codes if the services provided do not match the requirements for a whole obstetric package. These could include antepartum care only, delivery only, postpartum care only, delivery and postpartum care, etc.

Unless the patient presents issues outside the global package, individual Evaluation and Management (E&M) codes shouldn’t bill to record maternity visits.

Global Package excludes Prenatal care as it will bill separately. Based on the billed CPT code, the provider will only get one payment for the full-service course.

Services involved in the Global OB-GYN Package.

A key part of OBGYN medical billing services is understanding what is and is not part of the Global Package.

There are three areas in which the services offered to patients as part of the Global Package fall. As follows:

Antepartum care: Care provided from conception to (but excluding) the delivery of the fetus.

Intrapartum care: “Inpatient care of the passage of the fetus and placenta from the womb.”

Postpartum care: Care provided to the mother after fetus delivery.

Antepartum Care

The initial prenatal history and examination, as well as the following prenatal history and physical examination, are all parts of antepartum care. This includes:

  • Up to birth, all standard prenatal appointments (a total of 13 patient encounters)
  • monthly check-ins till 28 weeks of pregnancy
  • biweekly appointments till 36 weeks of gestation
  • visitations every week from 36 weeks until delivery
  • Recording of blood pressures, weight, and fetal heart tones
  • Routine chemical urinalysis (CPT codes 81000 & 81002)
  • Education on breastfeeding, lactation, and pregnancy (Medicaid patients)
  • Exercise consultation or nutrition counseling during pregnancy

IMPORTANT: Any unrelated visits or services shall code separately within this period.

Intrapartum Care

Delivery and labor consist of:

  • Including history and physical upon admission to the hospital
  • Inpatient evaluation and management (E/M) services provided within 24 hours of delivery
  • Uncomplicated labor management and fetal observation
  • administration or induction of oxytocin intravenously (performed by the provider, not the anesthesiologist)
  • Vaginal, cesarean section delivery, delivery of placenta only (the operative report)
  • Insertion of a cervical dilator on the same date as to delivery, placement catheterization or catheter insertion, artificial rupture of membranes.

Postpartum Care

Postpartum care includes the following.

  • Uncomplicated inpatient visits following delivery
  • Repair of first- or second-degree lacerations (for lacerations of the third or fourth degree, see “Services included in the Global OBGYN Package”)
  • simple cerclage removal (not under anesthesia)
  • Routine outpatient E/M services offered no later than six weeks after birth (check insurance guidelines for the exact postpartum period)
  • Prior to discharge, discuss contraception.
  • Postpartum outpatient treatment – thorough office visit
  • Breastfeeding, lactation, and basic newborn care are instances of educational services.
  • Simple remedies and care for nipple issues and/or infection

Important: Only one CPT code will have used to bill for everything stated above. It is not appropriate to compensate separate CPT codes as part of the global package.

Services Excluded from the Global OBGYN Medical Billing Package

Certain OB-GYN care procedures are extremely complex or not essential for all patients. Because of this, most patients and providers would find it inappropriate to include these treatments in the Global Package as they make the OBGYN Medical billing hard.

The global package excludes some procedures compiled by the American College of Obstetricians and Gynecologists (ACOG).

If the provider performs any of the following procedures during the pregnancy, separate billing should be done as the Global Package does not cover these procedures.

  • Initial E/M to diagnose pregnancy if the antepartum record is not started at this confirmatory visit
    • This is usually done during the first 12 weeks before the ACOG antepartum note is started. Use CPT Category II code 0500F.
    • Z32.01 is the ICD-10-CM diagnosis code to support this confirmation visit (amenorrhea).
  • Laboratory tests (excluding routine chemical urinalysis)
    • Examples include liver functions, HIV testing, CBC, Blood glucose testing, sexually transmitted disease screening, antibody screening for Hepatitis or Rubella, etc.
  • Fetal Maternal or echography procedures
  • Pregnancy ultrasound, NST, or fetal biophysical profile
    • Depending on the insurance carrier, all subsequent ultrasounds after the first three consider bundled.
  • Fetal contraction stress test
  • Cerclage, or the placement of a cervical dilator longer than 24 hours after admission,
  • Amnioinfusion
  • Amniocentesis (any method)
  • Inpatient E/M services provided more than 24 hours before delivery
  • Chorionic villus sampling (CVS)
  • External cephalic version (turning of the baby due to malposition)
  • Surgical Procedures during pregnancy
  • ACOG coding guidelines recommend reporting this using modifier 22 of the CPT code.
  • Examples include the urinary system, nervous system, cardiovascular, etc.
  • Contraceptive management services (insertions)
  • Laceration repair of a third- or fourth-degree laceration at the time of delivery

OBGYN Medical Billing Services CPT Code List

The AMA classifies CPT codes for maternity care and delivery. The full list of all potential CPT codes for pregnant women at full term listed below;

Important: This list does not cover pregnancy-related complications, including missed or incomplete abortions and pregnancy terminations.

The 2022 CPT codebook also contains the following codes.

CPT Description Package
59400 Routine OB GYN care, including antepartum care, vaginal delivery (with or without episiotomy and forceps), and postpartum care Global Package CodeVaginal Delivery
59409 Vaginal delivery only (with or without episiotomy and forceps); Itemization Code
59410 Vaginal delivery only (with or without episiotomy and forceps); including postpartum care Itemization Code
E/M Antepartum care only; 1-3 visits Itemization Code
59425 Antepartum care only; 4-6 visits Itemization Code
59426 Antepartum care only; 7 or more visits Itemization Code
59430 Postpartum care only (separate procedure) Itemization Code
59510 Routine OBGYN care, including antepartum care, cesarean delivery, and postpartum care Global Package Code C-Section Delivery
59514 Cesarean delivery only; Itemization Code
59515 Cesarean delivery only; including postpartum care Itemization Code
59610 After previous cesarean delivery, routine OBGYN care, including antepartum care, vaginal delivery (with or without episiotomy or forceps), and postpartum care. Global Package Code VBAC Delivery
59612 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and forceps); Itemization Code
59614 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and forceps); including postpartum care Itemization Code
59618 Routine OB GYN care, including antepartum care, cesarean delivery, and postpartum care, following attempted vaginal delivery after previous cesarean delivery Global Package CodeVBAC Delivery
59620 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery; Itemization Code
59622 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery, including postpartum care. Itemization Code

 OBGYN Medical Billing CPT Code List for High-Risk Pregnancies

In a high-risk pregnancy, the mother and/or baby may be more likely to experience health issues before, during, or after birth. More attention throughout pregnancy will require in this situation, requiring more than 13 prenatal visits.

Pregnancy at high risk could take the following forms:

Maternal age: After the age of 35, pregnancy risks increase for mothers.

Pre-gestational medical complications such as hypertension, diabetes, epilepsy, thyroid disease, blood or heart conditions, poorly controlled asthma, and infections might raise the chance of pregnancy.

Complications related to pregnancy include, for instance, gestation, diabetes, hypertension, stunted fetal growth, preterm membrane rupture, improper placenta position, etc.

All these conditions require a higher and closer degree of patient care than a patient with an uncomplicated pregnancy.

Therefore, Visits for a high-risk pregnancy does not consider as usual. It is essential to report these codes along with the global OBGYN Billing CPT codes 5940059510, 59610, or 59618.

The provider may submit extra E/M codes and modifier 25 to indicate that the care was significant and distinct from usual antepartum care if medical necessity is established. It is critical to include the proper high-risk or difficult diagnosis code with the claim.

Following ICD-10 employed for High-Risk Pregnancies OBGYN Medical Billing Services

ICD-10-CM Description
O09.899- Supervision of other high-risk pregnancies
O10.119- Pre-existing hypertensive heart disease complicating pregnancy
O11.9- Pre-existing hypertension with pre-eclampsia
O12.20- Gestational [pregnancy-induced] edema and proteinuria without hypertension
O11.4- Pre-eclampsia
O24.011- Pre-existing type-1 diabetes mellitus, in pregnancy,
O26.61- Liver and biliary tract disorders in pregnancy
O99-019- Anemia in pregnancy

Note: When a patient who was deemed high risk during her pregnancy had an uncomplicated birth without the need for additional monitoring or care, it should be coded as normal delivery.

Ultrasound OB-GYN MEDICAL Billing

It is essential to strictly follow maternity care OBGYN medical billing and coding requirements while reporting ultrasound procedures.

Keep a written report from the provider and have pictures stored, in particular. Image retention is mandatory for all diagnostic and procedure guidance ultrasounds in accordance with AMA CPT and ultrasound documentation requirements.

For each procedure coded, the appropriate image(s) depicting the pertinent anatomy/pathology should be kept and made available for review. CPT does not specify how the pictures stored or how many images are required.

Modifiers may be applicable if there is more than one fetus and multiple distinct procedures performed at the same encounter.  Incorrectly reporting the modifier will cause the claim line to deny.

The following CPT codes have covered a range of possible performed ultrasound recordings. Make sure your practice is following proper guidelines for reporting each CPT code.

76801–76810: Maternal and Fetal Evaluation (Transabdominal Approach, By Trimester)

76811–76812: Above and Detailed Fetal Anatomical Evaluation

76813–76814: Fetal Nuchal Translucency Measurement

76818–76819: Fetal Biophysical Profile

76815: Limited Trans-Abdominal Ultrasound Study

59025: Fetal Non-Stress Test

76816: Follow-Up Trans-Abdominal Ultrasound Study

76817: Trans-Vaginal Ultrasound Study

The coder must carefully review and study all the parenthetical guidelines that explain how to correctly bill the service for multiple gestations and more than one type of ultrasound.

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At BF we offer unparalleled OB-GYN medical billing services across all 50 states of the US. Our Billing services are tailored to the provider’s needs and meet the mandatory coding guidelines to ensure smooth claim processing. We have more than 5 years of OB-GYN Medical Billing experience and with our unique strategies stimulated several-trembling revenue cycle management. Furthermore, Our RCM services are fully updated with robust CMS guidelines.

How BillingFreedom can help your OB/GYN practice?

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  • Significantly boost collection and reduce denial rates.
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  • We help OB/GYN practices like yours to grow.

Modernize Your OB/GYN Billing Process

Coding for OB/GYN services can be complicated. One aspect of sound revenue cycle management and essential to the success of your OB/GYN clinic is precise and effective coding.

So why waste money and resources on outdated, cumbersome billing process?

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